Programme Effectiveness of an Integrated Programme to Reduce Maternal and Child Malnutrition in Kenya: Cluster Randomized, Parallel-group, Prospective, Follow-up Effectiveness Study in Children 6-35 Months of Age at Recruitment

Background/introduction:

Malnutrition, and particularly malnutrition in children under 5 years of age, remains a public health problem in many areas of the world [1]. A diet low in diversity and micronutrient density is one contributing factor while a second factor is poor water, sanitation and hygiene (WASH) practices often leading to diseases such as persistent diarrhoea and resulting in morbidity and mortality in children under 5 years of age. According to the WHO World Health Statistics 2017 that are monitoring health in order to reach the Sustainable Development Goals (SDGs) [2] including data from between 2006 and 2015, the global under 5 mortality rate per 1000 live birth is 42.5 and is clearly highest in the African Region with 81.3 while in Kenya it is lower than the African average with 49.4. The picture is similar for maternal mortality with 216 per 100,000 live births globally but with the highest in the African region with 542 and 510 in Kenya.

The statistics also look at several WASH indicators. The mortality rate attributed to exposure to unsafe WASH services per 100,000 populations is clearly highest in the African region with a burden of 43.1, while the global burden is at 12.4, and with Kenya slightly below the African burden with 32.5. In line with this, two additional WASH indicators demonstrate the poor status in the African region. The use of improved drinking water source is lowest in the African region with 68%, while globally 91% use an improved source and in all the other WHO regions it is over 90%. Kenya is slightly below the African average with 63% using an improved drinking water source. Looking at sanitation the use of improved sanitation is lowest in the African region with only 32% and is similar at the Kenyan level with 30% while globally 68% use improved sanitation. The most recent Kenya Demographic and Health Survey in 2014 estimates that only about a third of households in Kenya have washing places at their homes [3]. Also, nationally, three out of four households share toilets with other households or have unimproved toilets (open defecation, open latrines, etc.). Malnutrition is specifically covered in SDG Target 2.2 (By end 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons). The WHO statistics indicate a worldwide problem with 22.9% of children under 5 years of age stunted and 7.7% wasted. While the Africa Region (33.5% and 7.4%)) together with the South-East-Asia Region (33.8% and 15.3)) have the highest stunting and wasting prevalence, respectively, the prevalence in Kenya is below the Africa average with 26.0% stunted and only 4% wasted.

Agriculture is the main source of income, food and nutrients for the majority of rural families in Sub-Saharan Africa including Kenya. Most rural families in Sub-Saharan Africa are smallholder farmers, and rely on agricultural produce for income and direct consumption. Despite the fact that these households are food producers, research has shown that rural farming households are typically net food consumers and are more vulnerable to malnutrition [4]. Decades of investments in the agriculture sector have focused on improving yields and income but have notably failed to improve the nutrition status of farming families and their children [5]. Since 2006, One Acre Fund (1AF) has been providing a bundle of services and agricultural inputs to smallholder farmers using a model where farmers take loans to pay for inputs and services received. The core service bundle includes environmentally appropriate seed and fertilizer, physical delivery of inputs, training, and small loans. 1AF currently reaches 445,000 farming households in Kenya, Burundi, Rwanda, Tanzania, Malawi, and Uganda. Kenya was 1AF's first country of operation and their activities will soon cover all of Western and Nyanza Provinces, which are the primary food-producing regions and hold one third of Kenya's population. The most recent 1AF report impressively shows the increasing number of farm families served, the Dollar gain in farmer impact and the close to 100% farmer repayment rate of credits for seeds and fertilizers [6].

In partnership with the Children's Investment Fund Foundation (CIFF), 1AF aims to introduce nutrition-sensitive and nutrition-specific components into the services offered to smallholder farmer households. The nutrition-specific interventions consist of providing MNPs (Micronutrient Powders) to children 6-59 months of age. These nutritional supplements are recommended by WHO in areas where micronutrient deficiencies and malnutrition are prevalent [7,8]. In order to increase protein consumption, chicken birds will be provided to households. Households will also be provided with seeds for red onion and indigenous greens. Further, children will be provided with oral rehydration salts (ORS) and zinc supplements as recommended by WHO and UNICEF for the treatment of acute diarrhoea [9]. Lastly, some WASH related interventions will also be provided, such as training sessions, soap for hand washing and chlorine for drinking water treatment.